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Injury Report Template
Clearly record injury incidents for safety, insurance, HR, and legal or administrative records.
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Injury Report Template
[Organization / Employer / School / Program Name]
[Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]
1. Injured Person Information
Full Name: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]
Role (check or describe):
Employee
Student / Child
Athlete / Participant
Visitor / Customer
Contractor / Vendor
Other: [Describe]
Home Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
2. Incident Date, Time, and Location
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Location of Incident (room, area, field, worksite, street, etc.): [Location]
Type of Setting (check one):
Workplace
School / Childcare
Sports / Recreation
Public place / Business
Roadway / Vehicle / DUI-Related
Home / Residential
Other: [Describe]
3. Activity at the Time of Injury
Describe what the injured person was doing at the time of the incident (be specific):
[Example: “Lifting boxes onto a shelf,” “Running during PE class,” “Walking through hallway,” “Driving northbound on [Street],” “Playing in a soccer match.”]
Was this a normal / expected activity for this setting?
Yes
No – explain: [Brief explanation]
4. Description of Incident
Provide a clear, factual description of how the incident occurred. Avoid opinions or assigning blame; focus on what happened.
Description of Incident:
[Free-text narrative. Suggested points to cover:]
What was happening immediately before the incident.
How the injury occurred (slip, trip, fall, struck by object, collision, sudden movement, etc.).
Surfaces, equipment, vehicles, or substances involved (wet floor, steps, machinery, another vehicle, ball, etc.).
How the injured person landed, was struck, twisted, or otherwise hurt.
5. Injury Details
Body Part(s) Injured (check or describe):
Head / Scalp
Face / Eye / Nose / Mouth
Neck
Shoulder / Arm / Elbow / Wrist / Hand
Chest / Ribs
Back / Spine
Hip / Thigh
Knee / Lower Leg
Ankle / Foot / Toes
Multiple areas
Other: [Describe]
Side of Body: [Left / Right / Both / Center / Unknown]
Type of Injury (check all that apply):
Bruise / Contusion
Cut / Laceration / Scratch
Abrasion / Graze
Sprain / Strain
Suspected Fracture / Dislocation
Burn (thermal / chemical / electrical)
Bite / Sting
Concussion / Head Impact (suspected)
Other: [Describe]
Visible Signs of Injury:
[Example: redness, swelling, bleeding, deformity, limited movement, discoloration.]
6. Symptoms and Pain
Injured Person’s Reported Symptoms (use their own words where possible):
[Free-text, e.g., “sharp pain in right ankle when walking,” “headache,” “dizziness,” “nausea,” “numbness in fingers.”]
Pain Level (0–10 scale; 0 = no pain, 10 = worst pain imaginable):
Reported Pain Score: [0–10]
Other Observed Signs (check or describe):
Dizziness / unsteady gait
Confusion / disorientation
Difficulty speaking or responding
Shortness of breath
Pale / sweaty / clammy skin
Loss of consciousness (approximate duration: [Time])
Vomiting
Other: [Describe]
7. Immediate Response and Treatment
Did the injured person stop activity immediately?
Yes
No – explain: [Brief explanation]
Person(s) Providing First Aid or Initial Response:
Name(s) and Role(s): [List]
Care Provided On-Site (check all that apply):
Area cleaned
Bandage / dressing applied
Ice pack / cold compress
Pressure applied to control bleeding
Immobilization (splint, sling, brace)
Elevation of injured area
Rest and observation in designated area
CPR or emergency life support (briefly describe)
Other: [Describe]
Was 911 / Emergency Medical Services called?
Yes
No
If Yes:
Time Called: [HH:MM a.m./p.m.]
Responding Agency: [Name]
Transported to Medical Facility? [Yes / No]
Facility Name: [Hospital / Clinic Name]
8. Medical Evaluation and Work/School Status
Did the injured person receive or seek medical evaluation after leaving the scene?
Yes
No
Unknown at time of report
If Yes, specify:
Facility / Provider Name: [Name]
Type of Facility: [ER / Urgent Care / Clinic / Personal Doctor / Other]
Date of Visit: [MM/DD/YYYY]
Has a doctor or medical provider given written work, school, or activity restrictions?
Yes – describe: [e.g., “No sports for 2 weeks,” “No lifting over 10 lbs,” “Seated work only.”]
No
Unknown
Work / School Status Immediately After Incident:
Returned to normal duties / activities
Returned with temporary restrictions
Sent home
Transported for medical care
Other: [Describe]
9. Witness Information
Were there any witnesses to the incident?
Yes
No
Unknown
Witness 1:
Full Name: [Name]
Role (employee, student, customer, etc.): [Role]
Phone / Email (if needed): [Contact]
Brief Witness Statement (summary of what was seen or heard):
[Free-text summary]
Witness 2:
Full Name: [Name]
Role: [Role]
Phone / Email: [Contact]
Brief Witness Statement:
[Free-text summary]
[Add additional witness sections as needed.]
10. Notifications
Person(s) Notified (check and complete):
Parent / Guardian
Supervisor / Manager
HR / Safety Department
School / Program Administrator
Property Owner / Landlord
Other: [Describe]
Details:
Name of Person Notified: [Name]
Role / Relationship: [Role]
Method of Notification: [In person / Phone / Voicemail / Email / Other]
Date and Time of Notification: [MM/DD/YYYY – HH:MM a.m./p.m.]
Summary of What Was Communicated:
[Free-text summary]
11. Follow-Up and Corrective Actions
Planned or Completed Follow-Up Actions (check or describe):
Monitor injured person’s condition at subsequent visits / shifts.
Request medical documentation or work status note.
Inspect area, equipment, or conditions involved.
Repair, clean, or modify equipment or environment.
Provide refresher training or safety reminder.
Update internal policies or procedures.
Other: [Describe]
Person Responsible for Follow-Up: [Name and Title]
Target Date for Completion: [MM/DD/YYYY]
12. Signatures
Reporting Person
I certify that this Injury Report reflects my understanding of the incident and information available at the time of completion.
Name: [Reporting Person Full Name]
Position / Role: [Title / Relationship]
Signature: ___________________________
Date: [MM/DD/YYYY]
Supervisor / Administrator Review (if applicable)
I have reviewed this report and will ensure that appropriate follow-up and safety actions are considered and, where approved, implemented.
Name: [Supervisor / Administrator Name]
Title: [Title]
Signature: ___________________________
Date: [MM/DD/YYYY]
Injured Person / Parent / Guardian Acknowledgment (if required)
I acknowledge that I have been informed of the contents of this Injury Report. This acknowledgment does not indicate agreement with any conclusions and is not a waiver of any rights.
Name: [Injured Person / Parent / Guardian]
Signature: ___________________________
Date: [MM/DD/YYYY]
13. Additional Notes or Attachments
Additional Notes:
[Free-text area for any other relevant information not covered above.]
Attachments (check if included):
Photos of injury or scene
Separate incident / accident investigation report
Medical note or discharge summary
Internal safety or HR forms
Other: [Describe]
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Learn more about
Injury Report Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
INJURY REPORT TEMPLATE FAQ
What is an injury report?
An injury report is a written record of an incident in which a person is hurt or shows signs of injury. It typically includes when and where the incident occurred, what the person was doing at the time, how the injury happened, which body parts were affected, what care was provided, and who was informed.
Who should complete an injury report?
An injury report is usually completed by the person who was injured (if able) or by a responsible adult who witnessed or responded to the incident — such as a supervisor, teacher, coach, safety officer, or manager. In some organizations a second person, such as HR or an administrator, reviews and signs the report.
When should an injury report be filled out?
It is generally best to complete an injury report as soon as reasonably possible after the incident — preferably the same day — while details are still fresh. Many workplaces, schools, and programs require a written report for any incident that causes injury or could reasonably have caused injury, even if it seems minor at first.
What information should be included in an injury report?
A helpful injury report usually includes: basic information about the injured person; date, time, and location of the incident; a factual description of what happened; body parts injured and type of injury; visible signs and reported symptoms; first aid or medical care provided; witness information; notifications made to supervisors, parents, or HR; and any initial follow-up or safety actions.
Can this injury report template be used for workplace, school, sports, or accident cases?
Yes. This Injury Report Template is designed to be flexible and can be adapted for workplaces, schools and childcare settings, sports and recreation programs, customer or visitor incidents, and motor vehicle or DUI-related crashes. You can modify section titles and questions to match your organization’s policies or regulatory requirements.
Can AI Lawyer help me customize my injury report?
Yes. AI Lawyer can help you adjust the wording, layout, and sections of this Injury Report Template to fit your organization, industry, or jurisdiction. You still need to follow your own policies and any applicable laws or regulations, and provide accurate facts for each incident. This template and any AI-generated content are for general information and document organization only and are not legal, medical, or safety advice.
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